Children's emotional reactivity and negative affect predict future ADHD symptom severity beyond initial ADHD symptom severity.

Children with Attention-Deficit/Hyperactivity Disorder (ADHD) often experience significant emotion dysregulation. However, there is limited longitudinal data on associations between multiple aspects of emotion dysregulation and ADHD symptoms. Additionally, given substantial evidence that increased levels and variability of negative affect (NA) are identified in children with ADHD, it is important to examine the role of NA in this relationship. The present study used momentary and longitudinal data to examine the relation between two aspects of emotion dysregulation (emotional lability and emotional reactivity), the two ADHD symptom clusters separately (inattentive and hyperactive/impulsive), total ADHD symptom severity, and NA variability over a period of six months. Participants (N = 68) were parents of children aged 7-12 years old (M = 9.80, SD = 1.34) who completed baseline and 6-month follow-up reports of children's ADHD symptoms and emotion dysregulation as well as ecological momentary assessments (EMA) of their children's NA for one week. Results were threefold: (1) children's emotional reactivity predicted inattentive, hyperactive/impulsive, and total ADHD symptom severity above and beyond initial ADHD symptom severity, but emotional lability did not significantly predict severity of any ADHD symptom cluster; (2) NA variability predicted hyperactive/impulsive and total ADHD symptom severity, but not inattentive severity; and (3) initial ADHD symptom severity did not predict emotion dysregulation at follow-up. The current study provides novel insight regarding the longitudinal influence of specific aspects of emotion dysregulation and NA on ADHD symptom severity in children and suggests that targeting emotional reactivity could minimize ADHD symptom severity.

Indirect effect of ADHD on parenting stress through increased child anxiety and decreased emotional regulatory coping.

Parents of children with ADHD experience significantly more parenting stress in comparison to parents of typically developing children due to the emotional and behavioral difficulties related to ADHD. Additionally, approximately 30% of children with ADHD experience co-occurring anxiety. Parents of children with co-occurring anxiety and ADHD report increased stress due to role restriction and isolation compared to parents of children with ADHD alone. Poor emotional regulatory coping in children with ADHD has been linked to elevated negative affect and irritability, which also contributes to increased stress among parents. The present study examined the direct and indirect associations of child anxiety symptoms and emotional regulatory coping on elevated ADHD symptoms and parenting stress. Participants were 203 children aged 7-12-years-old and their parents. Parents completed a self-report measure of parenting stress and measures of their child's ADHD symptoms, anxiety, and emotional regulatory coping. Additionally, children completed self-report measures of emotional regulatory coping. Model testing indicated that the overall model demonstrated excellent fit to the data. Parameter testing supported an indirect effect of child ADHD symptoms on parenting stress through child anxiety symptoms and an indirect effect of child ADHD symptoms on parenting stress through child emotional regulatory coping. These results suggest that child anxiety and emotion dysregulation in children with ADHD have a negative impact on parental stress. The current study adds to the understanding of the important roles emotional regulatory coping and anxiety play in children with ADHD to contribute to increased parenting stress.

Examining the influence of irritability and ADHD on domains of parenting stress.

Parents of children with ADHD typically report higher levels of parenting stress than parents of typically developing children. Children with ADHD display developmentally inappropriate levels of hyperactivity, impulsivity, and inattention. Some children with ADHD are also prone to particularly high levels of tonic irritability that may explain some of the impairments typically found in ADHD. The present study sought to determine the unique impact of ADHD and tonic irritability on child-related parenting stress domains (e.g., difficult child, parent-child dysfunctional interactions). 145 mothers of children with and without ADHD aged 7-12 years participated in the current study. Mothers completed self-report measures of parenting stress as well as a diagnostic structured interview. Ecological momentary assessment (EMA) was used to assess tonic irritability in an ecological environment. Indirect effects models were specified using PROCESS Model 4. For the parent-child dysfunctional interaction domain, the data were best fit by a model specifying a significant total effect of ADHD that was fully accounted for by an indirect effect through irritability. For the difficult child domain, model testing indicated a significant total effect of ADHD that was partially accounted for by an indirect effect through irritability. The current study adds support to the growing body of literature acknowledging the role of tonic irritability in children with ADHD. Furthermore, the results provide novel insight in the complex relation of irritability, child ADHD, and domains of parenting stress.

Comorbid Internalizing and Externalizing Disorders Predict Lability of Negative Emotions Among Children With ADHD.

Objective: A subset of children with ADHD experience more frequent, sudden, and intense shifts toward negative emotions. The current study utilized ecological momentary assessment (EMA) to provide a valid assessment of the impact of comorbid internalizing and externalizing disorders on negative emotional lability (EL) among children with ADHD. Method: Parents of 58, 8- to 12-year-old children with ADHD were administered a diagnostic interview to assess for ADHD and for the presence of comorbid disorders. Parents completed EMA-based ratings of their child's negative emotions three times daily for a total of 28 days. Results: Children with a comorbid internalizing disorder or children with comorbid oppositional defiant disorder (ODD) experienced significantly greater EMA-derived negative EL than children without comorbid disorders over time. Children with multiple comorbidities experienced greater EL than children with single comorbidities. Conclusion: Overall, this study suggested that both comorbid ODD and comorbid internalizing disorders contribute to negative EL among children with ADHD.

Temperamental negative affect, emotion-specific regulation, and concurrent internalizing and externalizing pathology among children with ADHD.

Children with attention-deficit/hyperactivity disorder (ADHD) experience high rates of temperamental negative affect and comorbid internalizing and externalizing pathology. The current study explored the role of emotion-specific regulation in accounting for the link between temperamental negative affect and psychopathology among children with ADHD. Forty parents of children ages 8-11 (N =29 males, N =11 females) completed measures of child temperament, emotion-specific dysregulation (i.e., anger dysregulation, sadness dysregulation), and psychopathology. Children completed a measure of emotion-specific dysregulation. Results revealed that anger dysregulation fully statistically accounted for the relationship between temperamental negative affect and concurrent externalizing problems. Sadness dysregulation did not account for the relationship between temperamental negative affect and internalizing problems. These novel findings implicate the robust role of anger dysregulation in explaining the link between temperamental negative affect and concurrent externalizing pathology. The results of this study have significant implications for the treatment of emotionally driven externalizing behavior among children with ADHD.

How do children with and without ADHD talk about frustration?: Use of a novel emotion narrative recall task.

Children with attention-deficit/hyperactivity disorder (ADHD) experience difficulties related to emotional reactivity and regulation. The current study examines differences in the emotional reactivity and regulation of children with and without ADHD in the context of their real-life experiences of negative emotion using a novel ecologically valid methodology. Eighty-three 8-12-year-old children (46 ADHD, 38 non-ADHD) participated in the study. Children completed the negative emotion narrative recall task, a novel task whereby children provided a narrative recall of a real-life event where they experienced negative emotion. ANCOVA indicated children with ADHD recalled significantly more overall frustration and intense frustration than children without ADHD. Children with ADHD exhibiting more negative emotional reactivity while recalling negative emotions than children without ADHD. The current study suggests that children with ADHD are uniquely impacted by negative emotional experiences and represents an important step in understanding the emotional reactivity and regulation of children with ADHD.

Relation between internalizing behaviors, externalizing behaviors, and peer victimization among children with and without ADHD.

The current study explored the concurrent and longitudinal association between internalizing behaviors, externalizing behaviors, and peer victimization among children with and without ADHD. Eighty children (42 ADHD, 38 non-ADHD) ages 8-12 participated in the present study conducted over a 6-month period. During the baseline session, parents completed a structured diagnostic interview and the Vanderbilt ADHD Parent Rating Scale to determine whether their child met criteria for ADHD, and the Child Behavior Checklist (CBCL) to assess their child's internalizing and externalizing behaviors; children completed the Perception of Peer Support Scale (PPSS) to assess experiences of peer victimization. At the 6-month follow-up session, parents completed the CBCL and children completed the PPSS. Concurrently, internalizing behaviors were associated with peer victimization among children with and without ADHD; ADHD moderated this relation, such that internalizing behaviors were more strongly related to peer victimization among children with ADHD. Longitudinally, internalizing behaviors at baseline predicted peer victimization at 6-month follow-up; however, further analyses demonstrated there was a covarying change in internalizing behaviors and peer victimization. These findings suggest internalizing behaviors are related to peer victimization concurrently, and over time, and are associated with increased risk for peer victimization in the presence of ADHD. Additionally, internalizing behaviors and peer victimization appear to share a dynamic relationship; that is, decreases in internalizing behaviors predict similar decreases in peer victimization. No significant relations were observed between externalizing behaviors and peer victimization. Implications and limitations are discussed.

Functional Impairment Variability in Children With ADHD Due to Emotional Impulsivity.

OBJECTIVE: The present study utilized ecological momentary assessment (EMA) to examine the effects of emotional impulsivity on overall functional impairment and functional impairment variability (FIV) of children with and without ADHD. METHOD: Parents of 74 children, 8- to 12-year-olds (42 with ADHD, 32 without ADHD), completed EMA assessment protocol ratings of their child's mood (3 times daily) and functional impairment (1 time daily) over the course of 28 days. RESULTS: Hierarchical regression analyses supported the interaction of ADHD diagnostic status and greater EMA-derived emotional impulsivity in the estimation of total functional impairment (Total FI) and FIV. Thus, greater emotional impulsivity was found to be related to greater Total FI and FIV among children with ADHD but not among children without ADHD. CONCLUSION: This study suggests that children with ADHD and greater emotional impulsivity demonstrate greater overall levels of functional impairment, with the severity of their impairment varying significantly over time.

Intolerance of uncertainty in children with attention-deficit/hyperactivity disorder.

Intolerance of uncertainty (IU) has often been studied in the context of internalizing disorders, but no studies to our knowledge have explored the relation between IU and externalizing disorders. Given the proposed link between IU and emotion regulation, the current study sought to examine levels of IU in an externalizing clinical population with known emotion regulation difficulties-attention-deficit/hyperactivity disorder (ADHD). IU levels in this population were compared to a clinical population known to experience elevated levels of IU. Participants in present study were ninety-three children (36 anxiety disorder, 28 ADHD, 29 unaffected children) ages 7-13, who completed the Intolerance of Uncertainty Scale-Short Version (IUS). Responses on the IUS were converted to total IU, prospective IU, and inhibitory IU. A linear mixed model analysis of covariance was conducted while controlling for age, sex, and ADHD medications. A significant interaction was observed between diagnostic status and IU scale. Planned contrasts indicated that children with anxiety disorders and ADHD reported significantly higher levels of IU relative to unaffected children, and children with ADHD reported comparable levels of inhibitory IU relative to children with anxiety disorders. The current results contribute to a growing literature on the link between IU and psychopathology. IU appears to be a transdiagnostic construct present among children with internalizing and externalizing disorders, and may be broadly associated with emotion regulation deficits rather than specific disorder symptoms.

The Relation of Poor Emotional Awareness and Externalizing Behavior Among Children With ADHD.

OBJECTIVE: Children with ADHD often demonstrate poor emotional self-awareness and higher levels of externalizing behavior problems relative to unaffected children. This study examined the relation of deficient emotional self-awareness to externalizing behavior problems in children with ADHD, and the role of emotional reactivity in this relationship. METHOD: Fifty-one 8- to 12-year-old children with ADHD and their parents completed measures of the children's emotional and behavioral functioning, as well as a diagnostic structured interview. RESULTS: Logistic regression suggested that more impaired emotional self-awareness was strongly associated with the diagnosis of a comorbid externalizing disorder. Hierarchical regression analyses strongly supported the relation of poor emotional awareness to reactivity-driven externalizing behavior, but not to proactive externalizing behavior. These effects were evident across reporters. CONCLUSION: This study suggested that poor emotional self-awareness is significantly linked to externalizing problems in children with ADHD, and that dysregulated emotional reactivity plays an important role in this relationship.

The association of emotional lability and emotional and behavioral difficulties among children with and without ADHD.

Children with ADHD often demonstrate a pattern of emotional lability characterized by sudden and intense shifts in affect. Emotional lability has been linked to emotional and behavioral problems in children with and without ADHD, but few studies have examined emotional lability over time. This study examined the effects of emotional lability over time on the behavioral and emotional difficulties of children with and without ADHD using an ecological momentary assessment (EMA) methodology. One hundred and two children aged 8-12 years (56 with ADHD and 46 without ADHD) and their parents completed baseline measures of the children's behavioral and emotional difficulties. Parents then completed a 28-day 3-times daily EMA assessment protocol to rate their child's emotional lability. Results suggested that emotional lability was associated with internalizing and/or externalizing diagnoses independent of ADHD diagnostic status, but was not directly associated with ADHD. Hierarchical regression analyses supported ADHD diagnostic status as a moderator of the association of greater EMA-derived emotional lability with children's behavioral difficulties, such that greater emotional lability was associated with greater behavioral difficulties among children with ADHD but not among children without ADHD. Results indicated that greater emotional lability was directly linked with greater emotional difficulties and that this relation was not moderated by ADHD diagnostic status. Overall, this study suggested that emotional lability is related to emotional difficulties independent of ADHD, but is differentially related to behavioral difficulties among children with and without ADHD.

Emotional Impulsivity and Emotional and Behavioral Difficulties Among Children With ADHD: An Ecological Momentary Assessment Study.

OBJECTIVE: Children with ADHD often demonstrate impulsive shifts in emotion, characterized by sudden and intense shifts in affect. This study examined the effects of emotional impulsivity over time on the emotional and behavioral functioning of children with ADHD using ecological momentary assessment (EMA). METHOD: Twenty-seven 8- to 12-year-old children with ADHD, and their parents, completed baseline measures of the children's emotional and behavioral functioning. Parents and children then completed an EMA protocol, whereby they each rated the child's affect three times daily for 28 days. RESULTS: Hierarchical regression analyses strongly supported the relation of greater EMA-derived emotional impulsivity to children's increased emotional and behavioral difficulties. These effects were evident across reporters and were maintained after controlling for baseline emotion dysregulation. CONCLUSION: Overall, this study demonstrated the utility of EMA-based assessments and suggested that emotional impulsivity may play an important role in the emotional and behavioral functioning of children with ADHD.

Social Self Control, Externalizing Behavior, and Peer Liking Among Children with ADHD-CT: A Mediation Model.

This study investigated the role of externalizing behavior as a mediator of the relation between social self-control and peer liking among children with Attention-Deficit/Hyperactivity Disorder-Combined Type (ADHD-CT). A model was proposed whereby externalizing behavior would fully statistically account for the direct relation of social self-control to peer liking. One hundred seventy two children ages 7.0-9.9 years with ADHD-CT were rated by their teachers regarding their social self-control and by their parents and teachers regarding their rates of externalizing behavior. Same-sex classmates provided ratings of overall liking. Structural Equation Modeling (SEM) was used to assess the proposed model. Results supported the proposed model of externalizing behavior as fully statistically accounting for the relation of social self-control to peer liking. This study demonstrated the crucial role that externalizing behaviors play in the social impairment commonly seen among children with ADHD-CT.

I know it when I quantify it: ecological momentary assessment and recurrence quantification analysis of emotion dysregulation in children with ADHD.

Two studies examined the feasibility, utility, and validity of Ecological Momentary Assessment (EMA) and Recurrence Quantification Analysis (RQA) in assessing emotion dysregulation in children with Attention-Deficit/Hyperactivity Disorder (ADHD). In Study 1, 11 parents of children with ADHD ages 8-11 completed EMA-based ratings of their children's mood three times daily for 28 days (84 ratings total) and questionnaires regarding their children's emotion dysregulation. RQA was used to quantify the temporal patterning of dysregulation of the children's mood. In Study 2, five children ages 8-11 completed EMA-based ratings of their mood three times daily for 28 days. Results supported the feasibility and validity of the parent report EMA protocol, with greater intensity, variability, and persistent patterning of variability associated with greater emotion dysregulation. Results did not support the validity of the child report protocol, as children were less likely to complete ratings when emotionally distressed and demonstrated substantial response bias.

Dysregulated negative emotional reactivity as a predictor of chronic peer victimization in childhood.

This study examined the relations of dysregulated negative emotional reactivity, emotional distress, and chronic peer victimization in childhood. A model was proposed whereby dysregulated reactivity was directly and indirectly related to concurrent peer victimization through victimization-related emotional distress. The model further proposed that dysregulated reactivity directly incrementally predicted longitudinal peer victimization above and beyond the effect of concurrent victimization. Two hundred thirteen 9- to 13-year-old children and their parents completed measures of dysregulated reactivity and victimization experiences at baseline and 6-month follow-up. Children also related narratives of personal victimization experiences at baseline that were coded to assess victimization-related emotional distress. Model testing strongly supported the direct association of dysregulated reactivity with concurrent victimization and incremental predictive effects of dysregulated reactivity on peer victimization over time. Model testing also provided support for an indirect effect of dysregulated reactivity on concurrent peer victimization through victimization-related emotional distress. This study demonstrated the powerful role that dysregulated negative emotional reactivity plays in the development of chronic peer victimization over time.

Evidence for higher reaction time variability for children with ADHD on a range of cognitive tasks including reward and event rate manipulations.

OBJECTIVE: The purpose of the research study was to examine the manifestation of variability in reaction times (RT) in children with attention deficit hyperactivity disorder (ADHD) and to examine whether RT variability presented differently across a variety of neuropsychological tasks, was present across the two most common ADHD subtypes, and whether it was affected by reward and event rate (ER) manipulations. METHOD: Children with ADHD-combined type (n = 51), ADHD-predominantly inattentive type (n = 53), and 47 controls completed five neuropsychological tasks (Choice Discrimination Task, Child Attentional Network Task, Go/No-Go task, Stop Signal Task, and N-back task), each allowing trial-by-trial assessment of RTs. Multiple indicators of RT variability including RT standard deviation, coefficient of variation and ex-Gaussian tau were used. RESULTS: Children with ADHD demonstrated greater RT variability than controls across all five tasks as measured by the ex-Gaussian indicator tau. There were minimal differences in RT variability across the ADHD subtypes. Children with ADHD also had poorer task accuracy than controls across all tasks except the Choice Discrimination task. Although ER and reward manipulations did affect children's RT variability and task accuracy, these manipulations largely did not differentially affect children with ADHD compared to controls. RT variability and task accuracy were highly correlated across tasks. Removing variance attributable to RT variability from task accuracy did not appreciably affect between-groups differences in task accuracy. CONCLUSIONS: High RT variability is a ubiquitous and robust phenomenon in children with ADHD.

Mental health as a mediator of gender differences in employment barriers among drug abusers.

Employment has been identified as an important drug abuse treatment outcome, but drug abusers often face a wide variety of barriers to securing stable employment. The employment barriers literature also reports that women and people with mental health problems have difficulty in obtaining employment. The current study examined gender differences in mental health and employment barriers in a sample of drug court participants. Hierarchical regression analyses were conducted to test the hypothesis that differences in employment barriers among drug-abusing males and females are mediated by differences in mental health problems. Women were found to have more mental health problems and employment barriers, and support for the mediation hypothesis was found. Implications for drug treatment providers are discussed.

Gender, mental health, and treatment motivation in a drug court setting.

The current study examined differences in motivation for drug treatment in a sample of 500 (327 males and 173 females) drug court participants. It was hypothesized that females would report higher levels of treatment motivation, as indicated by measures of problem recognition and desire for help, and that this difference would be moderated by mental health. After controlling for selected factors related to treatment motivation, females were found to have higher levels of problem recognition and desire for help. A significant gender x mental health interaction was also found, suggesting that females with more mental health problems have the highest levels of desire for help.

Treatment motivation and therapeutic engagement in prison-based substance use treatment.

Studies of community-based substance use treatment show that motivation for treatment is critical for clients becoming therapeutically engaged. Little research, however, has been conducted on therapeutic engagement in corrections-based substance use treatment. The current study examines the association between internal treatment motivation and therapeutic engagement for a sample of 220 male substance-using offenders enrolled in a corrections-based treatment program. Findings showed that problem recognition and desire for help were associated with cognitive indicators of therapeutic engagement, specifically confidence in and commitment to treatment. Increased focus on internal motivation for treatment may lead to more effective treatment for substance-using offenders. Pretreatment motivational interventions therefore are recommended for substance-using offenders with low internal motivation for treatment.

Testing psychodynamic psychotherapy skills among psychiatric residents: the psychodynamic psychotherapy competency test.

OBJECTIVE: Training in psychodynamic psychotherapy remains a core requirement of psychiatric residency training programs, yet no standard measures of competency exist to document residents' knowledge and skills in this area. To address this issue, the authors developed a written test of applied knowledge of psychodynamic psychotherapy technique and theory, the Psychodynamic Psychotherapy Competency Test. Their goal in this article was to evaluate the validity of this test. METHOD: The test was given to a group of 36 psychoanalytic experts and 206 residents in their second, third, and fourth psychiatric postgraduate years from 10 programs located in different parts of the United States. Program directors provided information on the number of hours of psychodynamic didactic teaching, supervision, and resident-conducted psychodynamic psychotherapy and rated the psychodynamic psychotherapy skills of residents in their fourth postgraduate year on the basis of cumulative supervisor reports. RESULTS: There were significant differences in test performance between residents and faculty experts and between residents in their second and fourth postgraduate years: more advanced residents and experts had progressively better scores. The mean scores of fourth-year residents in different programs differed significantly, but the scores of second-year residents did not. Higher test scores were positively associated with both number of hours of resident-conducted psychotherapy and number of hours of supervision. Among fourth-year residents, test scores correlated significantly with program director evaluations. CONCLUSIONS: This initial study supports the validity of the Psychodynamic Psychotherapy Competency Test as well as the feasibility of testing psychotherapy skills in a standardized fashion.